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Sun Sep 13 17:02:54 BST 2009

I am sorry that I am late for this discussion.    As many of  you know so 
very well, I do not believe that the CT of the chest in acute trauma  gives 
much information to change decision making, except in mediastinal  traverse.  
  In the case presented I would have proceeded a bit  differently.    

1.   There is no need to do any of the attempts to elevate the BP  in the 
EC.   Either go to CT quickly on the way to the OR, or just to  the OR.   I 
would have obtained a CT after the initial chest X-ray,  but NOT to evaluate 
the great vessels

2.   I do not rely on CTA for evaluation of vessel injury  ANYWHERE.  I 
have been burned too many times in both  directions.   Injury not shown by CTA. 
  CTA reports an  injury which was not present.   AND believe me this is 
happening all  over the country, and world.  

3.    My first incision would have been the left  anteriolateral for 
control of any bleeding and removal of the clot which was not  evacuated by the 
chest tube.   

4.    As described, the surgeon discovered a T-2 esophageal  injury via the 
left thoracotomy.  Pretty good, as that area of the  esophagus is covered 
by the aorta and aortic arch.   So, in this  case the CT provided no 
information which would not have been provided at  the time of the thoracotomy

5.    I would have closed the left chest after hemorrhage  control, and 
performed a 4th interspace RIGHT posterolateral thoracotomy,  divided the 
azygous vein and repaired the esophagus, having obtained an  intercostal muscle 
flap on the way in to wrap the esophageal  repair.    It is almost impossible 
to fix an esophageal  injury through an anterior incision, especially a T-2 
injury via a  left anterolateral incision.   

6.    I would then make a decision to make an abdominal  incision via a 
midline laparotomy depending on what I had seen on the EC  abdominal x-ray, and 
the two chest incisions.     It appears  that the CT might have also have 
mislead the team.   

I am increasingly becoming disenchanted with CT for  most penetrating 
trauma.   

k

In a message dated 9/13/2009 10:02:43 A.M. Central Daylight Time,  
nmcswai at tulane.edu writes:

We did a  large study almost 20 years ago that showed NO INCREASE in
infection when  cell saver was used as compared to similar volume of
banked  blood

Norman

Norman McSwain MD
Professor - Tulane Univ.  SOM
Trauma Director - Charity Hospital
504 988 5111

-----Original  Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of Dr Timothy
Hardcastle
Sent: Sunday, September 13, 2009 3:16  AM
To: ?" Trauma-List [TRAUMA.ORG] "
Subject: Re: TRANSMEDIASTINAL  GSW

Why?
There is good evidence that the amount of contamination is  small and is
washed clean by the cellsaver, therefore safe to use this  blood - study
from Johannesburg by Bowley and Boffard clearly showed  that!

Dell wrote:
> We did have cellsaver ready and available,  but did not use because of
the
> esophageal injury

Tim
Dr T  C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS  (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer University  of KwaZulu-Natal Dept Surgery
Deputy Director - IALCH Trauma  Service
Durban - South Africa

Dr T C Hardcastle
M.B., Ch.B.  (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma  Surgeon /
Honorary Lecturer University of KwaZulu-Natal Dept  Surgery
Deputy Director - IALCH Trauma Service
Durban - South  Africa

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